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Tibial Plateau Fracture Treated with ORIF and Tibia Strut in a 37-year-old Male: A Case Report
No full textTibial plateau fractures (TPFs) are orthopedic challenges that have multiple injury modalities and clinical presentations. These fractures can be caused by high energy or low energy trauma. Epidemiological studies estimate peak incidence in the third and sixth decade of life for males and between the fourth and fifth decade for females. TPFs are often classified using the Schatzker classification system which can dictate management.
Case presentation: this is a 37-year-old male who complained of right knee pain after sustaining a fall from a truck ramp. The patient heard a pop and had severe, sharp pain in his right knee. In the emergency room, CT imaging demonstrated a comminuted tibial plateau fracture involving the medial and lateral tibial plateau as well as the metaphysis. The lateral tibial plateau was depressed by 5 mm. The patient was placed in a knee immobilizer, made non-weight bearing, and scheduled for surgical planning in 2 weeks. Unfortunately, the patient never followed up and opted for non-operative management. 6 months later, he came to our clinic because of significant pain and instability in the knee. X-rays demonstrated a chronic, incompletely healed fracture of the medial tibial metaphysis extending to the tibial eminence. Chronic fracture deformities of the medial femoral condyle and lateral tibial plateau were also observed. The patient agreed to surgery at our clinic.
The surgical technique was a proximal tibial osteotomy. An incision was made centered over the medial aspect of the gastrocnemius. The medial soft tissue sleeve was elevated off the proximal tibia in subperiosteal fashion while maintaining the MCL insertions. Next, a sagittal saw was used to make an osteotomy. The proximal tibia was elevated to correct for varus deformity. Afterwards, a fibula strut was placed followed by plate and screws. After biplanar x-ray verified adequate reduction and hardware replacement, bone filler was used to fill the void. Post operatively, the patient was made non-weight bearing for 3 months. Range of the motion was encouraged as tolerated.
At the first month follow up, the patient’s pain was well controlled and range of motion exercises were done regularly. No paresthesia, numbness, or wound dehiscence were noted. Repeat x-rays demonstrated intact hardware with evidence of healing fracture lines compared to immediate post-operative images. Fragments and the knee were appropriately aligned. No significant soft tissue or joint effusion were appreciated on imaging.
Conclusion: after failing nonoperative treatment, this patient with comminuted bicondylar tibial plateau fracture has received definitive treatment with open reduction and internal fixation. Higher rates of unacceptable results from nonoperative treatment is inline with Schatzker’s series in which operative treatment resulted in more acceptable outcomes. Because the fracture in this patient is more consistent with a Schatzker IV or V classification with intra-articular displacement more than 2 mm, the patient’s choice for nonoperative treatment was not appropriate. This led to a malunion and non-union that necessitated surgery. Perhaps greater warning should have been given to the patient about the risks of nonoperative treatment at their initial encounter
Editorial: Disparate roles of mitochondria in cell survival and cell death: new insight from the CNS
Get PDFThe author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest
Outcomes of XEN-45 Gel Stent in Open-Angle Glaucoma using the PoST Technique: 12-month Follow-up
No full textPurpose: The purpose of this study was to report the 12-month surgical outcomes of the novel PoST technique (Posterior Sweep of Tenon’s technique) in eyes undergoing glaucoma surgery with the XEN-45 Gel Stent.
Methods: A retrospective review was performed for patients who underwent ab interno implantation of a XEN-45 Gel Stent using the PoST technique with or without concurrent cataract surgery. The surgery was performed in adults with open-angle glaucoma that was refractory to prior surgical treatment and glaucoma medications.
Results: In total, 87 eyes of 70 patients aged 58 to 91 years were treated with the XEN-45 Gel Stent. 54 eyes (62%) had a prior glaucoma procedure to lower intraocular pressure (IOP), including laser peripheral iridotomy (LPI). 33 eyes (38%) did not have a prior glaucoma procedure.
Across all 87 eyes, the average IOP decrease at 12 months was 6.50 mmHg (28%), from 18.66 mmHg to 12.16 mmHg, with an average decrease of 2.37 (69%) glaucoma medications, from 3.36 to 0.99 anti-glaucoma medications. Patients with a prior glaucoma procedure had an average IOP decrease of 7.84 mmHg (33%) at 12 months with an average decrease of 2.39 (66%) glaucoma medications. In patients without a prior glaucoma procedure, at 12 months, the average IOP decrease was 4.29 mmHg (20%) on an average of 2.33 (74%) fewer medications. An average of 62.76 micrograms of mitomycin C was used during XEN surgery, ranging from 30 to 80 micrograms.
Across all eyes, the mean IOP at 12-month follow-up was significantly reduced compared to preoperative IOP (P<0.0001). The number of glaucoma medications was also significantly decreased from baseline (P<0.0001) at 12 months. The average IOP decrease in patients without concurrent cataract surgery was significantly greater than in patients with combined XEN and cataract surgery (8 vs. 4 mmHg; P<0.01).
Among all study eyes, there were 28 total complications at or after 1 week post-surgery. The most common types of complication were IOP spike > 12 mmHg (55%), followed by blockage of XEN tip in anterior capsule (21%) and blockage of XEN implant (7%). Patients with at least one previous glaucoma procedure were 4.51 times more likely (OR = 4.51, p= 0.0336) to experience a complication after XEN Gel Stent implantation, compared with patients with no previous glaucoma procedures.
The cumulative proportion of failure was 0.35 for patients with a previous glaucoma procedure and 0.21 for patients without any prior glaucoma procedures, totaling 0.3 for all eyes. Eight patients (9%) required needling after XEN implantation. The cumulative proportion of re-operation was 0.22.
Conclusions:
In this study, the XEN-45 Gel Stent was safe and effective in treating 70% to 80% of patients with refractory glaucoma. The use of the PoST technique provided significant IOP and anti-glaucoma medication reduction compared to pre-operative levels. Additionally, the post-operative needling rate is significantly lower than those previously published. The PoST technique should be considered when using the XEN-45 gel stent in glaucoma patients who have failed previous surgical treatment or are taking multiple glaucoma medications without adequate IOP control
Craving for Change: Culturally Tailored E-Health Intervention to Support SMART Goal Setting of Lifestyle Modifications Among Underserved Racial/Ethnic Families to Combat Obesity
No full textPurpose: Examine the impact of the mixed-method intervention program Family Central E-Health, utilizing interactive, culturally tailored, e-health text messaging to promote healthy lifestyle behaviors in six domains (diet, physical activity, sleep, social connection, tobacco cessation, and stress management), and combat chronic disease such as obesity among a diverse racial/ethnic and low socioeconomic sample of caregivers of overweight/obese children. Methods: A sample of 14 adult caregivers of overweight/obese children receiving care from the University of North Texas Health Science Center Pediatric Mobile Clinic participated in the e-health intervention group (n = 8) or a control group of usual care (n = 6). The transtheoretical behavior change framework was applied to health briefs shared through a bi-directional text messaging software to customize SMART (Specific, Measurable, Attainable, Relevant, and Time) goal setting, monitor attitude (motivation and confidence), and assess behavioral change on the six domains of lifestyle modifications. The study aims were accomplished through weekly surveys throughout the study (6-month duration), at study close, 3 months post-intervention, and 6 months post-intervention. Results: Longitudinal analysis and differences in overall means of motivation and confidence between the two groups were minimal and not statistically significant. Descriptive thematic analysis of the participants’ attitudes and experiences revealed lifestyle modification domains of physical activity, social connection, and stress management with the most utilization in SMART goal setting and initiating health-promoting behaviors. Conclusion: The Family Central E-Health intervention may be an effective and culturally sensitive model for managing and preventing obesity, and alike chronic diseases among diverse racial/ethnic and/or low socioeconomic caregivers and their families. Reduction of harmful health behaviors and initiation of health-promoting behaviors through SMART goal setting within the six lifestyle domains can help address existing health disparities. Health education and lifestyle modification interventions are important and future directions include investigating participant empowerment, resiliency, and wellbeing, especially within underserved and diverse communities
Implications of Interactive Online Medical Education for TCOM Musculoskeletal Education
No full textPurpose:
In the modern medical curriculum, students are required to learn increasing amounts of information, and the ability to adapt and expand the threshold of fundamental concepts is becoming increasingly important. Most recently, the COVID-19 pandemic has forced the medical education system to adapt to a new challenge - delivering a comprehensive medical education to students remotely without compromising the quality of education. As a result, online interactive learning modules were introduced into the second exam portion of the TCOM Musculoskeletal Systems 2 (MSS2) course. This study aims to retrospectively review the effects of this online, interactive, module-based format.
Methods:
A retrospective review was performed to compare student performance before and after the implementation of these pandemic related changes. De-identified student data (n=685) from the 2019 pre-pandemic cohort and the 2020 and 2021 post-pandemic cohorts were utilized for the study. The dataset included student cumulative medical school GPA prior to the beginning of the course, class quartile rank, MSS2 exam scores and final course grades. Standard post-course surveys were utilized for the qualitative portion of the analysis, and an additional course satisfaction survey administered via google polls was added for the purpose of collecting anonymous student feedback and suggestions for improvement. Quantitative analysis was conducted on parametric and non-parametric variables. For parametric variables, the independent sample T-test was utilized to assess significant differences in a number of different variables, including both broad and specific statistical questions regarding the data.
Results:
The implementation of the online musculoskeletal modules correlated to a significant difference between the course grades of the 2019 and 2020 cohorts with mean scores of 88.4 and 87.2 respectively (p=.025). A significant improvement was found in the second exam for the 2019 and 2020 cohorts (p=.006), whereas no significant difference was revealed between the first exam grades of the two cohorts (p = 0.49). The data analysis from the two years following the pandemic demonstrated a successful implementation of online modules with the significant improvement of exam grades in the second exam where the modules were incorporated, including in the 2021 cohort. These significant findings indicate a benefit of introducing such modules into the second exam. Post-course surveys revealed that 57% of students want to see interactive modules in future courses, with an additional 28% being neutral.
Conclusions:
The addition of interactive modules to the MSS2 curriculum was beneficial as students were able perform significantly better on the relevant exam material despite entering the course with significantly lower GPAs. Furthermore, the majority of students responded positively to the possibility of seeing interactive modules used in future courses
Neonatal Diabetic Ketoacidosis - A Case Report
No full textBackground: Neonatal diabetes mellitus (NDM) is a rare condition (1 in 400,000 live births). It generally presents within the first 6 months of life and may be transient or permanent. The transient form is commonly associated with paternal isodisomy and monogenic variants, such as KCNJ11 and ABCC8, located on chromosome 6. The permanent form is also associated with monogenic variants, most commonly KCNJ11 and ABCC8. Diabetic ketoacidosis (DKA), which is common in older children and teens with autoimmune diabetes mellitus (T1D), is rare in NDM and often overlooked. Case Study: A 1-day-old female with low birthweight (2.520 kg) was referred to Cook Children’s Medical Center for tachypnea (78 to 84 bpm) and hyperglycemia. Her blood pH was 7.22 (7.29 – 7.24), pCO2 <12 (27- 40 mmHg), pO2 122 (54-95 mmHg), and HCO3 of 4.1 (19.0-24.0 mmol/L). Blood glucose levels were >200 mg/dL. Due to persistent respiratory symptoms, she was suspected of being septic and was treated with ampicillin and gentamicin. She was on the cutoff for SGA. Within the initial 48 hours of admission, her lab test results were consistent with DKA - blood glucose of 305 mg/dL (50-96 normal), lactic acid of 2.3 mmol/L (0.5-2.0 normal), anion gap of 21 (10-16 normal) and B-hydroxybutyrate of 9 mmol/L (0.4-0.5 normal). Genetic testing showed a variant of unknown significance in HNF1a. Following stabilization, the parents underwent diabetes education, and the infant was discharged on daily insulin therapy for follow-up in the Endocrine clinic. By 5 years-of-age, she continued to require daily injections of insulin for glucose control. This case is unique in that the infant was found to have a variant of unknown significance for HNF1a, a monogenic mutation that is typically seen in maturity-onset diabetes of the young (MODY). In general, MODY is not typically associated with DKA. Therefore, while our finding is intriguing, we cannot state that this variant is causative in the case we presented. Further reports of HNF1 variants are needed to help determine if there is an association with NDM and DKA. Conclusions: In infants, NDM and DKA are rare and present with nonspecific symptoms, which often delays the diagnosis. Although rare, it is imperative that NDM and DKA be considered in order to avoid adverse consequences, including death
Effect of selective ganglion stimulation on hypertension in systemic lupus erythematosus
No full textEffect of selective ganglion stimulation on hypertension in systemic lupus erythematosus
Keanna K. Johnson1, Viet Dinh2, Cassandra M. Young-Stubbs2, Caroline G. Shimoura2, Sarika Chaudhari2, Keisa W. Mathis2
1School of Public Health,2Department of Physiology and Anatomy, University of North Texas Health Science Center, Fort Worth, Texas
Purpose: Systemic lupus erythematous (SLE) is a female-dominant autoimmune disease that causes widespread inflammation in various organs. Inflammation precedes the prevalent hypertension in the disease. The cholinergic anti-inflammatory pathway (CAP) is an endogenous neuroimmune pathway that reduces inflammation upon stimulation. We hypothesize that stimulation of the CAP by selective activation of the superior cervical ganglion will halt disease progression and hypertension in SLE.
Methods: Female SLE (NZBWF1) and control (NZW) mice received unilateral microinjections of pAAV-hSyn-hM3D(Gq)-mCherry, a designer receptor exclusively activated by designer drug (DREADD), or pAAV-hSyn-mCherry (vehicle) at the superior cervical ganglion (SCG) at 32 weeks of age. SCG DREADD injections generate muscarinic receptors on SCG neurons that are activated by the designer drug, clozapine N-oxide (CNO), ultimately leading to neuronal stimulation and potentially activation of the CAP. At 33 weeks of age, mice with SCG DREADD received a daily s.c. injection of CNO (3mg/kg) for two weeks. At 35 weeks, mice received a catheter implant in the carotid artery to measure mean arterial pressure (MAP) for two consecutive days followed by euthanasia and tissue collection. Plasma was collected biweekly via retro-orbital bleeding. Plasma samples were used to quantify double-stranded (ds) DNA autoantibodies.
Results: dsDNA autoantibodies were higher in SLE than control mice (8.6e5 ± 1.8e5 vs. 5.1e4 ± 1.1e4 U/mL; p=0.0002; n=13). SCG DREADD did not change dsDNA autoantibody levels in SLE mice (1.1e6 ± 2.6e5 U/mL; p=0.1410; n=6) or control mice (5.4e4 ± 1.5e4 U/mL; p=0.6549; n=9). MAP was significantly higher in SLE mice compared to control mice (150 ± 9 vs. 122 ± 3 mmHg; p=0.0009; n=5–9). SCG DREADD did not change MAP in SLE mice (137 ± 2 mmHg; p=0.2572; n=6) or controls (127 ± 3 mmHg; p=0.7678; n=9).
Conclusion: These data suggest that selective activation of the CAP at the level of the SCG using DREADD did not significantly alter disease severity or blood pressure in female SLE mice with advanced disease. Future studies will determine the effect of selective ganglion stimulation on inflammatory outcomes.
Funding: Research reported in this abstract was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number R25HL125447. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number R25HL12544
Impact of Endoscopic Vacuum-Assisted Closure on Quality of Life in Patients After Treatment of Gastrointestinal Leaks
Get PDFEndoscopic Vacuum Assisted Wound Closure (EVAC) is an effective therapeutic option to treat Gastrointestinal (GI) leaks after the surgery. Prior to EVAC, conventional approaches to treat leaks included surgical intervention or endoscopic stents. Even though EVAC has been in use for more than a decade and has proven to be successful in treating GI leaks, the long-term quality of life impact of this treatment is uncertain. With the use of a short form (SF-36) survey, a validated questionnaire to assess both physical and mental health, the long-term impact of EVAC on the quality of life was evaluated. When assessing the long-term quality of life for patients who are at least 2 years out from their sentinel surgery, the EVAC group scored higher in all 8 quality of life domains with 4 domains reaching statistical significance as compared with conventional therapy group which received other treatments for leak management
Modulation of Mitochondrial Metabolic Parameters and Antioxidant Enzymes in Healthy and Glaucomatous Trabecular Meshwork Cells with Hybrid Small Molecule SA-2
Get PDFOxidative stress (OS)-induced mitochondrial damage is a risk factor for primary open-angle glaucoma (POAG). Mitochondria-targeted novel antioxidant therapies could unearth promising drug candidates for the management of POAG. Previously, our dual-acting hybrid molecule SA-2 with nitric oxide-donating and antioxidant activity reduced intraocular pressure and improved aqueous humor outflow in rodent eyes. Here, we examined the mechanistic role of SA-2 in trabecular meshwork (TM) cells in vitro and measured the activity of intracellular antioxidant enzymes during OS. Primary human TM cells isolated from normal (hNTM) or glaucomatous (hGTM) post-mortem donors and transformed glaucomatous TM cells (GTM-3) were used for in vitro assays. We examined the effect of SA-2 on oxygen consumption rate (OCR) and extracellular acidification rate (ECAR) in vitro using Seahorse Analyzer with or without the oxidant, tert-butyl hydroperoxide (TBHP) treatment. Concentrations of total antioxidant enzymes, catalase (CAT), malondialdehyde (MDA), and glutathione peroxidase (GPx) were measured. We observed significant protection of both hNTM and hGTM cells from TBHP-induced cell death by SA-2. Antioxidant enzymes were elevated in SA-2-treated cells compared to TBHP-treated cells. In addition, SA-2 demonstrated an increase in mitochondrial metabolic parameters. Altogether, SA-2 protected both normal and glaucomatous TM cells from OS via increasing mitochondrial energy parameters and the activity of antioxidant enzymes.This research was funded by the National Institute of Health, grant number R01EY029823